Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 19
OPEN HELLER MYOTOMY
David B. Loran and Joseph B. Zwischenberger
STEP 1: SURGICAL ANATOMY
A comprehensive understanding of the anatomy of the thorax and esophagus is critical before undertaking surgical procedures on the esophagus.
Figure 19-1, A, demonstrates key anatomic structures that must be considered in an open Heller myotomy.
Anterior vagus nerve
Incision
Stenotic distal esophagus
|
MC |
A |
B |
|
FIGURE 19–1 |
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2 3 0 S E C T I O N I I I • TH E E S O P H A G U S
STEP 2: PREOPERATIVE CONSIDERATIONS
The word achalasia means “failure to relax,” which characterizes the pathophysiologic dysfunction of the lower esophageal sphincter in this disease. The sustained high-pressure zone is believed to be due to denervation or dysfunction of the nerves in Auerbach’s plexus, which leads to the loss of inhibitory effects of these ganglia on the muscles of the lower esophageal sphincter. Initiation of swallowing is normal; however, the esophagus cannot empty properly, which leads to varying degrees of dysphagia. Typical symptoms include odynophagia, foul breath, regurgitation of undigested food, and the patient describing a sensation of food “getting stuck” in his or her lower chest. Late symptoms result from the sequelae of continued aspiration and include hoarseness, pneumonitis, pneumonia, and lung abscess.
Diagnosis is based on patient symptoms and objective testing. Barium esophagram will show a mild to severely dilated esophageal body with a characteristically smooth “birdbeak” tapering at the distal esophagus. Manometry is the gold standard for diagnosis of achalasia and will show a loss of propulsive contractions in the esophageal body. Resting pressures at the lower esophageal sphincter can be normal to elevated with incomplete or completely absent relaxation upon swallowing. Esophagoscopy with biopsy is sometimes needed to rule out distal esophageal stricture due to esophagitis or carcinoma, which can mimic achalasia.
Once the diagnosis of achalasia is made, treatment usually begins with nonsurgical therapies. Botulinum toxin injected via an endoscope into the area of the lower esophageal sphincter can relieve symptoms in 50% to 65% of patients for as long as 18 months. Most have recurrence of symptoms beyond this time. Pneumatic or forceful bougie dilation of the lower esophageal sphincter has a long-term success rate approaching 70%. The gold standard for treatment of achalasia is surgical myotomy, with long-term success rates of 90% to 95%. Patients are usually treated with one or two attempts of nonsurgical therapies before being referred to a surgeon for myotomy. Those who are poor surgical candidates can be treated nonsurgically indefinitely.
Informed consent is obtained from the patient who is given nothing by mouth 8 hours before the procedure.
General endotracheal anesthesia is administered for this procedure.
The patient is placed in the lateral decubitus position with the right side down and secured to the operating table. The bed can be bent at the seventh to eighth intercostal space to facilitate exposure.
The skin is prepped with povidone-iodine (Betadine), from the top of the shoulder superiorly to the iliac crest inferiorly, then between the midline anteriorly and spinous processes posteriorly.
C H A P T E R 19 • Open Heller Myotomy |
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STEP 3: OPERATIVE STEPS
1.INCISION
A muscle-sparing minithoracotomy incision measuring 8 to 10 cm is placed in the seventh intercostal space (Figure 19-1, B). The serratus anterior muscle is separated to expose the intercostal muscles, which are removed from the superior aspect of the eighth rib to enter the chest. A rib retractor is placed.
2.DISSECTION
A size 40F to 44F bougie or Maloney dilator is placed by the anesthesiologist to facilitate dissection. The inferior pulmonary ligament is divided and the lung is retracted cephalad. The mediastinal pleura overlying the esophagus is incised from the gastroesophageal junction to the inferior pulmonary vein to expose the esophagus. This segment of esophagus is mobilized anteriorly if only a myotomy is planned or is completely mobilized and encircled with a Penrose drain if an antireflux procedure is added to the myotomy (Figure 19-2).
Care should be taken during this dissection not to injure either vagus nerve located at the lateral margins of the distal esophagus. Usually the vagus nerves are adherent and should not be mobilized (see Figure 19-2, B-C).
2 3 2 S E C T I O N I I I • TH E E S O P H A G U S
Anterior vagus nerve
Bulge in esophagus
A
Anterior vagus nerve
B
Anterior/posterior vagus nerve
Esophagus mobilized
C
FIGURE 19–2
C H A P T E R 19 • Open Heller Myotomy |
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The esophageal musculature is incised from the inferior pulmonary vein to the esophageal hiatus and extended onto the cardia of the stomach for approximately 1 to 2 cm
(Figure 19-3).
Incision
Anterior vagus nerve
A
Longitudinal muscle
Incision through circular muscle
FIGURE 19–3 |
B |
2 3 4 S E C T I O N I I I • TH E E S O P H A G U S
The esophageal muscle is gently divided longitudinally until the mucosa is seen to bulge from underneath (Figure 19-4).
A right-angle clamp or peanut dissector is used to raise the muscular wall from the mucosa over approximately 50% of the esophageal circumference. Care must be taken not to enter the esophageal lumen through the mucosa.
Submucosa
A
Longitudinal
muscle
Circular
muscle
Submucosa
FIGURE 19–4 |
B |
C H A P T E R 19 • Open Heller Myotomy |
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For the surgeon to inspect mucosal integrity, the bougie can be removed from the esophagus upon completion of the myotomy and replaced by a nasogastric (NG) tube. The chest cavity is filled with saline irrigation while the anesthesiologist gently injects air through the NG tube and the surgeon looks for air bubbles. If no air bubbles are seen, the Penrose drain is removed and the esophagus returns to its normal position (Figure 19-5). If the mucosa has been violated, the defect should be closed primarily with absorbable suture reapproximating the muscle fibers. An opposite site is then used for the myotomy.
Following completion of the myotomy, a chest tube is placed in the pleural space and exited through a separate incision in the lateral chest wall.
FIGURE 19–5
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Antireflux procedure, if added, is either a Belsey Mark IV (270 degree), Nissen (360 degree), or Dor (180 degree). Most surgeons add an antireflux procedure but no individual technique has proven superior (Figure 19-6).
FIGURE 19–6
C H A P T E R 19 • Open Heller Myotomy |
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3. CLOSING
The rib retractor is removed, and interrupted 0 Vicryl sutures are placed around the seventh and eighth ribs for closure of the chest cavity. Muscle layers are reapproximated with running 2-0 absorbable suture. The skin is closed with staples or a running 4-0 absorbable stitch. The chest tube is secured with a 2-0 silk drain stitch (Figure 19-7).
STEP 4: POSTOPERATIVE CARE
After recovery from anesthesia, the patient can be taken to a floor bed.
The chest tube should initially be placed to 15 to 20 cm H20 wall suction and the patient kept NPO.
On the second postoperative day, a contrast esophagram is obtained to ensure there is no leak from the myotomy site. With no leak present, a diet is initiated. If no esophageal leak is found, the lung is fully expanded. If there is no air leak present in the chest tube, the tube is removed. Patients are usually ambulatory by the second postoperative day and discharged to home by the third postoperative day.
FIGURE 19–7
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STEP 5: PEARLS AND PITFALLS
Without fundoplication, approximately 60% of patients report symptoms of reflux, most of which can be managed medically. Most surgeons therefore add an antireflux procedure to the myotomy. No technique has proven superior, but most avoid a 360-degree fundoplication because of its higher rate of dysphagia.
In prospective studies, laparoscopic Heller myotomy has been shown to achieve comparable outcomes with open surgery, with longer operative time and shorter hospital stay. Longterm follow-up has demonstrated satisfactory outcomes in 80% to 90% of cases.
Patients with esophageal dilation of up to 6 cm have had patient satisfaction of greater than 90% from laparoscopic Heller myotomy.
Patients with a sigmoid esophagus should be considered for myotomy first, then esophagectomy if symptoms do not resolve. Studies have demonstrated good to excellent patient satisfaction in 54% to 71% of patients at 7 to 11 years follow-up with myotomy of the sigmoid esophagus.
SELECTED REFERENCES
1. Tsiaoussis J, Athanasakis E, Pechlivanides G, et al: Long-term functional results after laparoscopic surgery for esophageal achalasia. Am J Surg 2007;193:26-31.
2. Constantini M, Zaninotto G, Guirroli E, et al: The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 2005;19:345-351.
3. Bonatti H, Hinder RA, Klocker J, et al: Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia. Am J Surg 2005;190:874-878.
4. Douard R, Gaudric M, Chaussade S, et al: Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery. Surgery 2004;136:16-24.
5. Gaissert HA, Lin N, Wain JC: Transthoracic Heller myotomy for esophageal achalasia: Analysis of longterm results. Ann Thorac Surg 2006;81:2044-2049.